General Insurance Claim

Is there any other Insurance in force which would cover this in whole or part

Yes

No

If Yes, please advise in the space provided.

Insurer’s Name

Policy Details

Are you registered for GST?

Yes

No

To what extent are you registered to claim an Input Tax Credit on the GST applicable to the premium?

Description of loss or damage

To assist in assessing the loss, the following information is requested.

Description 1

Date of Loss

Time

Description

Sum Claimed $

Date of purchase

From whom purchased

Purchase Price $

Replacement Value $

*Input Tax Credit %

*Please show the Input Tax Credit you are entitled to claim on the purchase of each item as a percentage of the total GST payable.

Description 2

Date of Loss

Time

Description

Sum Claimed $

Date of Purchase

From whom purchased

Purchase Price $

Replacement Value $

*Input Tax Credit %

*Please show the Input Tax Credit you are entitled to claim on the purchase of each item as a percentage of the total GST payable.

Description 3

Date of Loss

Time

Description

Sum Claimed $

Date of Purchase

From whom purchased

Purchase Price $

Replacement Value $

*Input Tax Credit %

*Please show the Input Tax Credit you are entitled to claim on the purchase of each item as a percentage of the total GST payable.

Total amount claimed $

Details of Loss Damage or Occurrence

Date of Loss / Damage / or Occurrence

Time

When was it reported to you? (If applicable)

Time

Place and/or premises where it occurred

Please state full details of how loss/damage/or accident occurred

Please describe nature of damage or injury

When were the Police notified? (If applicable)

Time

Police Station

Officers name

Police Report No.

Responsibility/Witnesses

In your opinion was any other person(s) responsible for loss or damage Or cause of the Occurrence?

Yes

No

Full Name

Address

Bus Phone

Private Phone

Fax No.

Reasons

Was there a witness or witnesses to this event?

Yes

No

If YES, please give full details.

Name of Witnesses

Witnesses’ Address

Bus Phone

Private Phone

Fax No.

Insurance History

Have you ever previously sustained loss/damage or caused damage or injury to 3rd parties

Yes

No

If YES, give details of such losses and amounts involved.

Was an Insurance Company involved?

Yes

No

If YES, please state name of company and year of claim.

Have you been convicted of or had any fines or penalties imposed for any criminal offences in the last 10 years?

Yes

No

If YES, please provide details.

Privacy

The Privacy Act 1988 requires us to tell you that we as broker and the insurer collect your personal and sensitive information in order to calculate your loss and entitlements, determine the insurer’s liability, compile data and handle claims. When handling claims we and the insurer may have to disclose your personal and other information to third parties such as other insurers, reinsurers, loss adjusters, external claims data collectors, investigators and agents, or other parties as required by law. Where you give us information about other persons you must have their consent to do this and provide it on their behalf. If not, you must tell us. You have the right to seek access to your personal information and to correct it at any time. Please contact us to advise if any changes are required.

Internal Dispute Resolution (IDR) Statement

Disputes are not an everyday occurrence. However insurers provide an internal dispute resolution process should any dispute arise. Please feel free to ask for details. If you are not satisfied with the outcome of that process, we will advise you how to contact the insurance industry’s external independent complaints scheme (subject to eligibility).

Declaration

1. I/We the insured do solemnly and sincerely declare that I/We have complied with the conditions and warranties (if any) of the policy and have not deliberately caused the said loss or damage or sought unjustly to benefit thereby by any fraud or misrepresentation and that the information shown on the form is true and the I/We have not concealed any information relating to this claim. I/We understand that this claim may be refused if the information
is untrue, inaccurate or concealed. 2. Further it is understood and agreed that if any property claimed for is subsequently recovered in an undamaged condition I/We will immediately refund the company any sum which may have been paid to me/us in respect of such property. In the event of any property being recovered in damaged condition I/We will immediately hand the same over to the company for disposal as may be agreed. 3. I/We acknowledge that I/We have read and understood the Privacy Act information referred to above and consent to the collection, storage, use and disclosure of personal and sensitive information of all persons affected by this claim. 4. I/We acknowledge that if I/We do not agree to the collection of this personal and sensitive information, then the broker and the insurer will be unable to process my/our claim.

Please provide bank details in order for your claim payment to be settled via EFT.